Get Ems Certificate/wallet Card Replacement Form - Dshs Texas

Filling out the EMS Certificate/Wallet Card Replacement Form is essential for anyone seeking to obtain a duplicate wallet card for emergency medical services. This guide provides a clear and structured approach to help you fill out the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section 1, provide your personnel data. Use black ink to type or print your information. Start by selecting the type of EMS certificate for which you are requesting a duplicate, such as EMT-P, EMT, or EMS Instructor.
3. Complete the personal information fields, including your last name, middle name, first name, and Social Security number. Note that the disclosure of your Social Security number is mandatory.
4. Fill in your residential address, including street address, city, state, and zip code. Include your home and business phone numbers as well.
5. Enter your date of birth in the format MM/DD/YY.
6. If you are claiming fee exemption, proceed to Section 2 and complete the Volunteer Sign-Off. This section requires approval from an EMS Provider or FRO administrator.
7. In Section 2, the administrator must confirm your exemption from payment, sign, print their name, and provide their contact information, including the DSHS license or registration number.
8. Once you've filled all required fields, move to Section 3. Sign and date the application, affirming that all provided information is true and correct.
9. Lastly, review the Privacy Notification provided on the form. Ensure that you understand your rights concerning the information collected by the State of Texas.
10. After completing the form, save your changes. You may download, print, or share the completed document as needed.

Take the step today to fill out your EMS Certificate/Wallet Card Replacement Form online.